Safety of pre-operative venogram for hemodialysis access planning in pre-end-stage kidney disease patients

Background: Although conventional pre-operative venography can accurately delineate venous anatomy as an alternative to ultrasound for hemodialysis access planning, it may carry a risk of contrast-induced acute kidney injury (AKI) and progression of renal failure in chronic kidney disease (CKD) patients not yet on dialysis. Therefore, the objective of this study was to evaluate the safety and efficacy of pre-operative venograms in pre-end-stage kidney disease (ESKD) patients.

Methods: We performed a retrospective cohort study (2018-2022) of consecutive pre-ESKD patients who underwent staged bilateral venograms for preoperative vein mapping prior to hemodialysis access creation at a tertiary care medical center. Patients were identified through an institutional database and data were extracted with chart review adjudication. The primary safety outcome was a composite of unplanned dialysis initiation within 7 days of venogram or development of contrast-induced AKI. Secondary outcomes included vascular access creation within 1 year of index venogram.

Results: A total of 142 pre-ESKD patients underwent 284 venograms. Mean (SD) age was 67 (14) years; 55% were female; and 65% of patients had stage 5 CKD, whereas 35% had stage 3 or 4 CKD. Rate of the primary safety outcome was 2.5%, which was driven by a 2.5% rate of contrast-induced AKI with no instances of unplanned dialysis initiation within 7 days of either venogram. Ultimately, 120 (85%) vascular accesses were created, of which 96% were autogenous fistulas. Forearm arteriovenous fistulas (AVFs) were the most common configuration (69%) followed by upper arm AVFs (27%); AV grafts were created in 4% of cases.

Conclusion: In a population of pre-ESKD patients, staged bilateral venograms led to few cases of reversible contrast-induced AKI with no instances of unplanned dialysis initiation. Furthermore, access creation was achieved in 85% of patients with the majority consisting of forearm AVFs. Therefore, preoperative venography for access planning appears safe in pre-ESKD patients.